Chapter 9 – Pain and Ethics
Thus far, we have examined the relationship between scientific ideology and the neglect
of major ethical dimensions of science, largely caused by the component of scientific ideology
that declares science to be “value free” and “ethics free”. But, while the explicit denial of
values is certainly going to be the most obvious cause of ethical neglect, we cannot
underestimate the more subtly corruptive influence of the second component of scientific
ideology we have delineated, the denial of the reality or knowability of subjective experiences in
people and animals.
Obviously, concern about how a person or animal feels—painful, fearful, threatened,
stressed—looms large in the tissue of ethical deliberation. If such feelings and experiences are
treated as scientifically unreal, or at least as scientifically unknowable, that will serve to
eliminate what we may term a major call to ethical deliberation and ethical thought. Insofar as
modern science tends to bracket subjectivity as outside of its purview, the tendency to ignore
ethics is potentiated. For example, in our discussion of animal research we have alluded to the
absence of pain control in animal research until it was mandated by federal legislation.
While this is certainly a function of science’s failure to recognize ethical questions in
science, society in general, except for issues of overt cruelty, also historically neglected ethical
questions about animals. Ordinary people, however, were comfortable in attributing felt pain to
animals, ( a matter of ordinary common sense) and adjusted their behavior accordingly, even in
the absence of an explicit ethic for animals being prevalent in society. Scientists, however, in
being trained out of ordinary common sense regarding animal subjective experience, were not
moved by what non-scientists saw as plainly a matter of pain. Hence one of my veterinarian
colleague’s response to my concern about howling and whining in his experimental surgery
dogs: “Oh that’s not pain, it is after-effects of anesthesia.”
In other words, the denial of the reality (or at least scientific knowability) of pain in
animals provided yet another vector for ignoring ethics, since ethical concern is so closely linked
to recognizing mental states. We shall, surprisingly, shortly document a similar problem in
human medicine.
It is certainly the case that modern science (i.e. the science beginning with Galileo,
Descartes, Newton, etc.) began with preconceptions uncongenial to taking subjective experience
as part of scientific reality. Medieval and Aristotelian science (Medieval science was at root
Aristotelian) set itself the task of explaining the world of sense experience and common sense
experience; a world of qualitative differences to which sense experience provided largely
accurate access which, when it failed, could be corrected by additional sense experience. As I
have explained elsewhere, Aristotelian science took the position that the world of ordinary
experience was the “real world”; that “what you see is what you get.” Indeed, that in my view
was one reason that the Aristotelian world-view lasted so long—it was based in and congenial to
ordinary experience.
This is, of course, not the case with the new science. Everyone who has taken
introductory philosophy recalls reading Descartes’ sustained attack on the senses and on
common sense, which was intended to undercut the old world view and prepare people to accept
that reality is not as it appears to be but as reason and mathematical physics tell us it is.
Descartes’ program was completed by Newton, but retained the same logic.
Thus, as we remarked at the beginning of this book, physical science became the
paradigm case for all science, with “objectivity” the primary mantra in all fields. Even the
social sciences strived to be “objective.” Subjective experiences were strongly disvalued (even
though science was said to be based in “experience”). By the 1920s, as I have recounted in
detail elsewhere, subjective experiences had been relegated to non-persons all across science,
with J.B. Watson and Behaviorism finally eliminating it even from psychology when Watson
skillfully sold the idea that psychology, in order to achieve parity with the “real” and successful
sciences, needed to become the science of rat behavior and learning. Indeed, Watson came
perilously close to affirming that “we don’t have thoughts, we only think we do!”
As long as we are discussing the Scientific Revolution, it is important to discuss, as we
briefly mentioned in our first chapter, that the Scientific Revolution itself presents us with a
superb example of a change in values. Consider the Aristotelian/common sense world view.
Can one imagine a crucial experiment that would falsify the claim that the world is best
understood in terms of adherence to sense experience, teleological explanations, qualitative
differences, and prove that such explanations must be abandoned in favor of mechanistic,
mathematical, quantitative explanations that ignore qualitative distinctions? Since experiments
set up in the Aristotelian paradigm would necessarily be qualitative, and since the paradigm
determines what counts as relevant data, how could such an experiment ever disprove the
paradigm itself? (The same of course, holds equally true for overturning an extant mechanistic
paradigm in favor of a qualitative one!) Thus the Aristotelian/common sense world view was
not falsified or disproved, it was rather set aside by virtue of the rise of new values that clashed
with it; for example the belief that God is a mathematician, and that under qualitative diversity
there must exist quantitative uniformity. The Aristotelian approach was more disapproved than
disproved!
As mechanism became the regnant conceptual paradigm for physics, its dominance was
gradually replicated in other sciences—chemistry, biology, geology, etc. This ideal was
enunciated in positivism, which affirmed in the twentieth century that psychology would be
reduced to neurophysiology, neurophysiology to biochemistry, chemistry to physics. For those
less radical, the move was nonetheless to eliminate the subjective from science, as Watson did
with turning psychology to the study of overt behavior. It is again noteworthy that this
transformation was not necessitated by experimental evidence or logical analysis overturning the
coherence of looking at subjective states. Indeed, as I have shown elsewhere, the alleged
historical inevitability of Behaviorism as reconstructed in histories of psychology will not stand
up to rational scrutiny. None of the major figures in psychology prior to Behaviorism
disavowed consciousness. In fact, Watson “sold” Behaviorism through rhetoric, arguing that
only by turning to the examination of overt behavior could psychology become analogous to
physics, and lead to the ability to socially manipulate behavior, to eliminate criminality and other
socially deviant behavior, which, in the end, is learned behavior.
The same pattern of what we may call “physicalization”—elimination of the subjective as
irrelevant to science—took place in medicine. Particularly with the rise of molecular biology
and sophisticated biochemistry, disease was increasingly seen as defects in the machine, and
subjective states as, to use Ryle’s apt phrase, “ghosts in the machine.” Even psychiatry, by the
end of the twentieth century, had come to see mental illness not as “mental” or “behavioral”, but
as biochemical—insufficiencies or excesses of certain chemicals. The management of such
diseases became a matter of balancing an individual’s chemistry, not of analysis or individual or
group therapy.
Traditionally, before the physicalistic turn, medicine was, and aspired to be, a
combination of science and art. The science component came, of course, from its attempt to
develop generalizable, lawlike knowledge that would remain invariant across space and time.
Such knowledge was sought regarding the working of the body, the nature of disease, and valid
therapeutic regimens, though medicine often fell short of the mark in all of these areas. The
element of art was patent in medicine. Art deals with the individual, the unique, with the
domain of proper names; with the person, not merely the body; with that which does not lend
itself to generalization, with the subjective psychological aspects of a persons well as with the
observable. A physician was thus expected to be both lawlike and intuitive, the latter not in any
mystical way, but rather in a manner that is focused on this particular individual and his or her
subjectivity and felt experience. And in understanding the individual—by definition
unique—all information, be it first-person reports or objective measurements, was relevant.
In some ways, the physicalization of medicine was a boon to sick people—there now
existed science and evidence-based ways to develop and test drugs and other therapies for safety
and efficacy. But, in other ways, it was a detriment. In the first place, how the patient felt
became significantly subordinated to how they objectively “were.” Medical success came to be
measured in terms of how long the patient lived; alive not dead and how long was an objective
parameter that could be quantified.
Cancer medicine provides an excellent example of this view. Oncology was directed at
eliminating the tumor and buying a measurable increment in life span, or time before death.
Quality of life, suffering attendant on chemotherapy or radiation, loss of dignity in the course of
treatment, psychological and economic toll on family; were not measures that scientific medicine
was wont to adopt. “Buying extra time” was the goal. And yet, as numerous authorities have
told us, patient concern is primarily about suffering, not about death per se.
In general, people who seek voluntary euthanasia do so because they fear pain, loss of
dignity (e.g., of the sort comes from incontinence), helplessness, dependence, stress on the
family. Obviously, they fear such experiences more than they fear death. Yet scientific
medicine does not worry about such “hindrances” to prolonging life. In particular, and crucial
to our argument in this chapter, felt pain becomes not fully medically real, since it is not
observable or objective, or mechanistically definable. In that regard, I vividly recall what one
nursing dean told me; “The difference between nurses and doctors is that we worry about care,
they worry about cure.” In turn, recall that the institution that has most concerned itself and
done the most for the terminally ill is hospice, and hospice was founded and is dominated by
nurses, not by physicians!
In 1973, psychiatrists R.M. Marks and E.S. Sacher published a seminal article on pain
control in which they demonstrated that almost 3 out of 4 cancer patients studied in two major
New York hospitals suffered (unnecessary) moderate to severe pain because of undermedication
with readily available narcotic analgesics. The authors were psychiatrists brought in to consult
on patients putatively having a marked emotional reaction to their disease. On examination,
they determined that the problem was undertreatment of pain leading to the emotional responses,
rather than a psychiatric problem! Though this article received a great deal of attention, this
disgraceful state of affairs was confirmed by other studies and by an extraordinary editorial in
Pain, fourteen years later, by John Liebeskind and Ron Melzack—two of the world’s most
eminent pain researchers:
We are appalled by the needless pain that plagues the people of the
world—in rich and poor nations alike. By any reasonable code, freedom from
pain should be a basic human right, limited only by our knowledge to achieve it.
Cancer pain can be virtually abolished in 80-90% of patients by the
intelligent use of drugs, yet millions of people suffer daily from cancer pain
without receiving adequate treatment. We have the techniques to alleviate many
acute and chronic pain conditions, including severe burn pain, labor pain, and
postsurgical pain, as well as pains of myofascial and neuropathic origin; but
worldwide, these pains are often mismanaged or ignored.
We are appalled, too, by the fact that pain is most poorly managed in those
most defenseless against it—the young and the elderly. Children often receive
little or no treatment, even for extremely severe pain, because of the myth that
they are less sensitive to pain than adults and more easily addicted to pain
medication. Pain in the elderly is often dismissed as something to be expected
and hence tolerated.
All this needless pain and suffering impoverishes the quality of life of
those afflicted and their families; it may even shorten life by impairing recovery
from surgery or disease. People suffering severe or unrelenting pain become
depressed. They may lose the will to live and fail to take normal
health-preserving measures; some commit suicide.
Part of the problem lies with health professionals who fail to administer
sufficient doses of opiate drugs for pain of acute or cancerous origin. They may
also be unaware of, or unskilled in using, many useful therapies and unable to
select the most effective ones for specific pain conditions. Failure to understand
the inevitable interplay between psychological and somatic aspects of pain
sometimes causes needed treatment to be withheld because the pain is viewed as
merely ‘psychological.’ [emphasis mine]
The final line of this editorial eloquently buttresses the account we have given of the
capture of medicine by a mechanistic and physicalistic ideology that denies reality to subjective
experience. Also highly relevant to our subsequent discussion is the strong claim that pain is
most egregiously ignored in the young and the elderly, i.e., those most vulnerable and
defenseless, a point we will return to shortly.
The ignoring of pain just detailed is further buttressed in a 1991 paper by Ferrel and
Rhiner that appeared in the Journal of Clinical Ethics. According to the authors, although pain
can be controlled effectively in 90% of cancer patients it is in fact not controlled in 80% of such
patients. A 1999 article in Nursing Standard shows that the Marks and Sacher problem
continued into the new century. The author affirms that “more recent studies have shown that
there has been little improvement over the years.” Supporting the points we made earlier, the
author is a nurse, not a doctor.
As pain was see as medically unreal and subjective, control of pain was historically
determined by strange ideological dicta even in the nineteenth century after the discovery of
anesthesia. Historian Martin Pernick has shown this point eloquently, by comparing hospital
records on anesthetic use with ideological pronouncements, and finding very high correlations.
For example, although affluent white women were generally the class receiving the most
anesthesia for most medical procedures, this was not true for childbirth, because it was believed
that childbirth pain was Divine punishment for Eve’s transgression and also that women would
not bond with the child unless they felt pain. Farmers, sailors, and other members of “macho”
professions received very little anesthesia, as did foreigners. Black women, even when being
used for painful experiments received no anesthesia at all. Limb amputation was classified as
“minor surgery.” Children received more pain control because of their “innocence” (which, as
we shall see, has been reversed under current ideology). Worries were expressed that anesthesia
gives the doctor too much (sexual) control over the patient. The key point is that pain control
even then was more a valuational and ideological decision than a strictly scientific medical one.
Thus, even with regard to anesthesia, precedent existed for odd and arbitrary
ideologically dictated use. Inevitably, given the tendency to see felt pain as scientifically less
than real, and in any case unverifiable, and further given the ethics-free ideology we have
discussed, a morally-based dispensation of pain control was unlikely to be regnant. Indeed we
have already quoted Liebeskind and Melzack on the tendency for pain management to be
minimal in the “defenseless.”
There is ample evidence for this claim. In 1994 a paper appeared in the New England
Journal of Medicine demonstrating that infants and children (who are of course powerless or
defenseless in the above sense), receive less analgesia for the same procedures then do adults
undergoing the same procedures. But there is a far more egregious example of the same point in
the surgical treatment of neonates—an example that never fails to elicit gasps of horror from
audiences when I recount it. This was the practice of doing open heart surgery on neonates
without anesthesia, but rather using “muscle relaxants” or paralytic drugs like succinylchlorine
and pancuronium bromide, until the late 1980s! Postsurgically, no analgesia was given.
Let us pause for a moment to explain some key concepts. Anesthesia means literally
without feeling. We are all familiar with general anesthetics which put a patient to sleep for
surgery. With general anesthesia, a person should feel no pain during a procedure. Similarly,
local anesthetics, such as novocaine for a dental procedure, remove the feeling of pain from a
particular area while procedures such as filling a tooth or sewing up a cut are performed, and the
patient is conscious but does not feel pain. Though there are many qualifications to this rough
and ready definition, they do not interfere with our point here.
Muscle relaxants or paralytics block transmission of nerve impulses across synapses and
thus produce flaccid paralysis but not anesthesia. In other words, one can feel pain fully but one
cannot move, which may indeed make pain worse, since pain is augmented by fear. First person
reports by knowledgeable physician/researchers of paralytic drugs, which paralyze the
respiratory muscles so the patient is incapable of breathing on his or her own, recount the
terrifying nature of the use of paralytics in conscious humans aware of what is happening.
Analgesics are drugs which attenuate pain or raise patients’ ability to tolerate pain. Examples
are aspirin and Tylenol for headaches, morphine, Demerol, Vicodin. Thus babies were
receiving major open heart surgery using only paralytic drugs, and experiencing countless
procedures ranging from circumcision and venipuncture to frequent heel-sticks with no drugs for
pain alleviation at all—neither anesthetics nor analgesics.
The public became informed about the open-heart surgery in 1985, when a parent, whose
own child died undergoing this sort of surgery, complained to the medical community, was
essentially ignored, and went public, supported by some operating room nurses who felt strongly
that babies experienced pain. The resulting public outcry caused the medical community to
reexamine the practice and eventually to abolish it.
The reasons anesthesia was ignored in neonates were multiple and familiarly ideological.
First of all, the medical community believed pain is “subjective” and thus not medically real.
Second, since babies do not remember pain, pain doesn’t matter. Third, it was argued and
widely accepted that the neonatal cortex or other parts of the nervous system were insufficiently
developed to experience pain. For example, it was said that babies’ nerves were insufficiently
myelinated for babies to feel pain. Fourth, since all anesthesia is selective poisoning, it was
argued that anesthesia was dangerous. Many of the claims which the objections to anesthesia
were based were deftly handled in a classic paper by Anand and Hickey, entitled “Pain and its
Effects in the Human Neonate and Fetus.”
To the first claim that pain is (merely) subjective, the reply is simple—first that is equally
true for adults and second, what is subjective is very real for the experiencer. (The essence of
pain is that it hurts). To the claim that forgotten pain doesn’t matter, the simple response is that,
once experienced, pain is biologically active and retards healing and is immunosuppressive even
if forgotten. To this day, painful procedures like bronchoscopy and colonoscopy are done under
amnesic drugs in adults, who may feel much pain during the procedure but don’t remember
because of the drug. Failure to remember does not justify infliction of pain. Furthermore
babies give evidence of memory when brought back to rooms in which they underwent surgery.
Third, Anand and Hickey convincingly debunk the claim that neonates—and even
preterm babies—do not feel pain. There are convincing physiological arguments that both
myelination and cortical development in neonates suffice to attribute pain to infants. Behavioral
changes also buttress this point.
Fourth, all anesthesia is dangerous, particularly when administered to sick people! The
key point is that adequate anesthesia regimens exist to tilt the cost-benefit ratio in favor of using
anesthesia. In a later paper (1992), Anand and Hickey showed that neonates given high doses of
anesthesia and analgesia for surgery fared better in terms of morbidity and mortality than
children treated with light anesthesia. They demonstrated that when infants undergoing open
heart surgery were deeply anesthetized and given high doses of opiates for 24 hours
postoperatively, they had a significantly better recovery and significantly fewer postoperative
deaths than a group receiving a lighter anesthetic regimen (halothane and morphine) followed
postoperatively by intermittent morphine and diazepam for analgesia. The group that received
deep anesthesia and profound analgesia “had a decreased incidence of sepsis, metabolic acidosis,
and disseminated intravascular coagulation and fewer postoperative deaths (none of the 30 given
sufentanil versus 4 of 15 given halothane plus morphine).”
The conclusion of Anand and Hickey’s 1987 paper is worth quoting in its entirety:
Numerous lines of evidence suggest that even in the human fetus, pain
pathways as well as cortical and subcortical centers necessary for pain perception
are well developed late in gestation, and the neurochemical systems now known
to be associated with pain transmission and modulation are intact and functional.
Physiologic responses to painful stimuli have been well documented in neonates
of various gestational ages and are reflected in hormonal, metabolic, and
cardiorespiratory changes similar to but greater than those observed in adult
subjects. [Emphasis mine] Other responses in newborn infants are suggestive of
integrated emotional and behavioral responses to pain and are retained in memory
long enough to modify subsequent behavior patterns.
None of the data cited herein tell us whether neonatal nociceptive activity
and associated responses are experienced subjectively by the neonate as pain
similar to that experienced by older children and adults. However, the evidence
does show that marked nociceptive activity clearly constitutes a physiologic and
perhaps even a psychological form of stress in premature or full-term neonates.
Attenuation of the deleterious effects of pathologic neonatal stress responses by
the use of various anesthetic techniques has now been demonstrated….The
evidence summarized in this paper provides a physiologic rationale for evaluating
the risks of sedation, analgesia, local anesthesia, or general anesthesia during
invasive procedures in neonates and young infants. Like persons caring for
patients of other ages, those caring for neonates must evaluate the risks and
benefits of using analgesic and anesthetic techniques in individual patients.
However, in decisions about the use of these techniques, current knowledge
suggests that humane considerations should apply as forcefully to the care of
neonates and young, nonverbal infants as they do to children and adults in similar
painful and stressful situations
It is interesting to note that, as in the case of pain in animals, the scientific
“reappropriation of common sense” about infant pain occurred only at the instigation of and
subsequent to public moral outrage about standard practice.
In a powerful and sensitive 1994 paper in the New England Journal of Medicine, Walco,
Cassidy, and Schechter review some of the major arguments leading to withholding pain control
from children and infants, echoing points we have seen made m Anand and Hickey. These
include the subjectivity of pain, the belief that children are not reliable reporters of pain, a failure
to recognize individual differences in children (despite solid scientific evidence to the contrary),
misinformation about the neurologic capacity to feel pain, the “no memory” argument. Recent
evidence indicates that this last point is particularly egregious, that not only does unrelieved pain
disturb eating, sleeping, arousal in the neonate, “infants retain a memory of previous experience,
and their response to a subsequent painful experience is altered,” and failure to control pain in
infants leads to aberrant nerve growth, causing additional pain later in life.
Walco et al also raise and refute the claim that opioid analgesics cause respiratory
depression or arrest. They point out that “the risk of narcotic induced respiratory depression in
adults is about 0.09 percent, whereas in children it ranges between 0 percent and 1.3 percent.”
In most cases, the problem is solved by dose reduction, and opiate overdose can be reversed.
They also indicate that fully 39% of physicians worry about creating addicts by use of opioids,
yet this concern is baseless, with “virtually no risk of addiction associated with the
administration of narcotics.” Another set of arguments affirms that masking pain masks
symptoms (a very common reason for not using analgesia in veterinary medicine), an absurd
claim regarding major surgical post-operative pain. An additional argument affirms that “pain
builds character,” again an absurd argument in an infant or suffering child. As Walco et al
declare “If there is a therapeutic benefit from a child’s pain, one must be exquisitely economical
with it.”
The conclusion of the Walco paper is as morally sensitive and powerful as the rest:
There are now published guidelines for the management of pain in
children, which are based on recent data. However, guidelines and continuing
medical education do not necessarily alter physicians’ behavior. Specific
administrative interventions are required. For example, hospitals may include
standards for the assessment and management of pain as part of their
quality-assurance programs. The Joint Commission on Accreditation of
Healthcare Organizations has established standards for pain management. To
meet such standards, multidisciplinary teams must develop specific treatment
protocols with the goal of reducing children’s pain and distress. In addition,
pressure from parents and the legal community is likely to affect clinical practice.
All health professionals should provide care that reflects the technological
growth of the field. The assessment and treatment of pain in children are
important parts of pediatric practice, and failure to provide adequate control of
pain amounts to substandard and unethical medical practice.
Many of the points made in the Walco paper have direct implications for other areas
where pain is neglected. For example, large portions of the medical community have steadfastly
opposed the use of narcotics in terminally ill patients on the dubious grounds that such patients
may become addicted. The first response, of course, is for people with a short time to live, “so
what if they become addicted—these drugs are cheap!” In any case, the medical community
ignorance in this area is appalling. Again from Walco:
It is essential to distinguish between physical dependence (a
physiologically determined state in which symptoms of withdrawal would occur if
the medication were not administered) and addiction (a psychological obsession
with the drug). Addiction to narcotics is rare among adults treated for
disease-related pain and appears to depend more on psychosocial factors than on
the disease or medically prescribed administration of narcotics. Studies of
children treated for pain associated with sickle cell disease or postoperative
recovery have found virtually no risk of addiction associated with the
administration of narcotics. There are no known physiologic or psychological
characteristics of children that make them more vulnerable to addiction than
adults.
We also find large numbers of physicians vehemently opposed to medical marijuana! It
appears that such physicians have gullibly brought into simplistic government propaganda about
drugs and addiction—“one shot and you’re hooked.” In fact, there were many regular heroin
users among soldiers in Vietnam who, when upon their return home were no longer in stressful
situations, gave up the drug use and were not addicted! Again we see ideology trump both
science and reason—in this case, the ideology underlying U.S. drug policy.
Another glaring example of medicine’s ignoring of subjective states can be found in the
history of the drug ketamine. This illustration is particularly valuable in that it demonstrates the
cavalier attitude that historically obtained (and indeed still obtains) with regard to negative
subjective experiences in humans and animals.
Ketamine is a cousin of phencyclidine. Phencyclidine (also known as PCP) was
developed in the 1950s but was found to be very dangerous in terms of hallucinations, creating
violent behavior, confusion, delusions, and abusability. Various derivatives of PCP were tried
until 1965, when ketamine was found to be most promising. In 1970, it was released for clinical
use in humans in the U.S.
Ketamine was heralded as the “ideal” anesthetic, since overdose was virtually impossible,
and it did not cause respiratory depression. Furthermore, it could be administered via
intravenous, intramuscular, oral, rectal, or nasal routes. Ketamine is profoundly analgesic (pain
relieving) for somatic or body pain, though it is of no use for visceral (gut) pain. It has been
particularly useful in human medicine for treating burn patients and changing dressings.
In the 1980s, while researching a paper on pain, I looked at ketamine in some detail. In
the first place, I found that it was used very frequently in research as a sole surgical anesthetic in
small rodents and other animals, and in veterinary practice as a standard “anesthetic” for spays.
Since it is emphatically not viscerally analgesic, this meant that in such procedures it was being
used as a restraint drug. Under ketamine, animals are “disassociated”—experience a strong
feeling of disassociation from the environment and are immobilized in terms of voluntary
movement. When I watched a visceral surgery on a cat done with ketamine, I could see obvious
signs of pain when the viscera were cut or manipulated. In essence, this means that when
ketamine alone was used for visceral procedures, the animals felt pain but were immobilized.
In human medicine, ketamine was used for a wide variety of somatic procedures, such as
burn dressing change and plastic surgery. But, by 1973, the medical community had become
aware of the fact that ketamine was capable of engendering significantly “bad trips” in a certain
percentage of patients, though many experienced pleasant hallucinations. A watershed
contributing to this awareness was a letter published in Anesthesiology in 1973 by Robert
Johnstone, wherein the contributor, an M.D. anesthesiologist, graphically described his
experiences under ketamine as a research subject. It is important to stress that Dr. Johnstone
had taken several different narcotics and sedatives before the ketamine experience and had had
no problems. The ketamine experience, however, was quite different:
I have given ketamine anesthesia and observed untoward psychic
reactions, but was not concerned about this possibility when the study began.
After my experience, I dropped out of the study, which called for two more
exposures of ketamine. In the several weeks since my ketamine trip, I have
experienced no flashbacks or bad dreams. Still I am afraid of ketamine. I doubt
I will ever take it again because I fear permanent psychologic damage. Nor will I
give ketamine to a patient as his sole anesthetic agent.
Here is Johnstone’s description of what occurred:
My first memory is of colors. I saw red everywhere, then a yellow square
on the left grew and crowded out the red. My vision faded, to be replaced by a
black and white checkerboard which zoomed to and from me. More patterns
appeared and faded, always in focus, with distinct edges and bright colors.
Gradually I realized my mind existed and could think. I wondered,
“What am I?” and “Where am I?” I had no consciousness of existing in a body; I
was a mind suspended in space. At times I was at the center of the earth in Ohio
(my former home), on a spaceship or in a small brightly-colored room without
doors or window. I had no control over where my mind floated. Periods of
thinking alternated with pure color hallucinations.
Then I remembered the drug study and reasoned something had
gone wrong. I remembered a story about a man who was awake during a
resuscitation and lived to describe his experience. “Am I dying or already dead?”
I was not afraid, I was more curious. “This is death. I am a soul, and I am going
to wherever souls go.” During this period I was observed to sit up, stare and then
lie down.
“Don’t leak around the mouthpiece!” were the first real sounds I heard. I
couldn’t respond because I didn’t have a body. Thus began my cycling into and
out of awareness—a frightening experience. I perceived the laboratory as the
intensive care unit; this meant something had gone wrong. I wanted to know
how bad things were. I now realized I wasn’t thinking properly. I recognized
voices, then I recognized people. I saw some people who weren’t really there. I
heard people talking, but could not understand them. The only sentence I
remember is “Are you all right?” Observers reported a panicked look and
defensive thrashing of my arms. I screamed “They’re after me!” and “They’re
going to get me!” I don’t recall this or remember the reassurances given me.
I then became aware of my body. My right arm seemed withered and my
left very long. I could not focus my eyes. Observers reported marked
nystagmus. I recognized the ceiling, but thought it was covered with worms
(apparently cued by the irregular depressions in the soundproof blocks). I
desperately wanted to know what was reality and to be part of it. I seemed to be
thinking at a normal rate, but couldn’t determine my circumstances. I couldn’t
speak or communicate, but once, recognizing a friend next to me, I hugged him
until I faded back to abstractness.
The investigators gave me diazepam, 20 mg, and thiopental, 150 mg,
intravenously because I was obviously anxious, and I fell asleep. When I awoke
it was five hours since I had received ketamine. I promptly vomited bilious
liquid. Although I could focus accurately, I walked unsteadily to the bathroom.
I assured everyone “I’m OK now.” Suddenly I cried with tears for no reason. I
knew I was crying but could not control myself. I fell asleep again for several
hours. When I awoke I talked rationally, was emotionally stable and felt hungry.
The next day I had a headache and felt weak, similar to the hangover from
alcohol, but functioned normally.
Today, of course, ketamine (known by the street name “special K”) is classified as a
Schedule III drug, not only because it is widely abused, but because it has become a rape drug, in
virtue of the immobility and “paralysis of will” it produces. And there are countless examples
in literature of vivid depictions of bad ketamine trips going back to 1973. An additional
troubling dimension of ketamine use became known at this time—the tendency of ketamine to
produce unpredictable “flashbacks,” much in the manner of LSD.
When researching all this in 1985, my main interest was its use in animals. I therefore
approached some world renowned veterinary anesthesia colleagues, who confirmed, first of all,
its misuse for visceral surgery. I then asked about “bad trips.” There was no literature on this,
I was told, but anecdotally, such occurrences were obvious. As my colleague put it, “Most
animals (cats) see little pink mice; but some see giant, ferocious pink rats.” Despite this
observation, I have never seen any discussion in the veterinary literature of “bad trips.”
Similarly, there is no literature on deviant behavior indicating possible flashbacks in animals, but
I have been told of owners reporting complete personality changes in animals after ketamine
dosing, one woman claiming that the hospital had given her back the wrong animal! The failure
of veterinary medicine to even discuss such potential problems eloquently attests to the
perceived irrelevance of bad subjective animal experiences to scientific veterinary medicine.
Continuing my research on ketamine in 1985-86, I was curious about how ketamine use
had changed since the 1973 revelations of bad trips and flashbacks. Much to my amazement, I
now found that ketamine was largely being used “on the very young (children) and the very old
(the elderly).”
For the next few months I searched the anesthesia literature, journals and textbooks, to
find out what unique physiological traits were common to the very young and the very old that
made ketamine a viable drug at these extremes, but not for people in the middle. I got nowhere.
Finally, by sheer coincidence, I happened to be at a party with a human anesthesiologist and
asked him about the differing physiologies. He burst out laughing! “Physiology?” he intoned.
“The use has nothing to do with physiology. It’s just not that the old and the young can’t sue
and have no power!” In other words, their bad subjective experiences don’t matter!
This was confirmed for me by one of my students, who had a rare disease since birth that
was treated at a major research center. He told me that procedures were done under ketamine,
which he loathed in virtue of “bad trips,” until he turned 16, at which time he was told,
“Ketamine won’t work anymore.”
If there ever was a beautiful illustration of ideological, amoral, cynical, denial of medical
relevance of subjective experience in human and veterinary medicine, it is the above account of
ketamine. Unfortunately, there is more to relate on this issue. We will now discuss the
International Association for the Study of Pain (IASP) definition of pain that was widely
disseminated until finally being revised in 2001 to mitigate some of the absurdity we shall
discuss.
IASP is the world’s largest and most influential organization devoted to the study of pain.
Yet, as we shall shortly detail, the official definition of pain entailed that infants, animals and
non-linguistic humans did not feel pain! In 1998, I was asked to criticize the official definition
of pain, which I felt was morally outrageous in its exclusion of the above from feeling pain and
in reinforcing the ideological denial of subjective experience to a large number of beings to
whom we had moral obligations. Leaving such a definition to affirm the scientific community’s
stance on felt pain was a matter causing both moral mischief and ultimately a loss of scientific
credibility. The discussion that follows is drawn from my remarks at the IASP convention of
1998, and my subsequent essay version published in Pain Forum.
It is a major irony that although the definition of pain adopted by the IASP was cast into
its current form for laudable moral reasons, it has given succor to neo-Cartesian tendencies in
science and medicine, and in fact has the potential for supporting morally problematic behavior.
Dr. Harold Merskey, a principle architect of the definition, has explained at the 1998 American
Pain Society meeting in San Diego that the initial definition of pain as “an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or described in terms
of such damage” was later modified in a note to allow for the reality of pain in adult humans
where there was no organic cause for the pain and no evident tissue damage. The note affirmed
that
Pain is always subjective. Each individual learns the application of the word through
experiences related to injury in early life.
It continues:
Many people report pain in the absence of tissue damage or any likely pathophysiological
cause: Usually this happens for psychological reasons. There is usually no way to
distinguish their experience from that due to tissue damage if we take the subjective
report. If they regard their experience as pain and if they report it in the same ways as
pain caused by tissue damage, it should be accepted as pain.
In other words, linguistic self-reports of pain should be accepted as proof of the existence
of genuine pain in linguistically competent beings, a move designed to encourage medical
attention to pain even in the absence of a proximate stimulus involving tissue damage. This was
clearly a praiseworthy, morally motivated move, which also spurred research into areas such as
chronic pain that might have been ignored in the absence of a definition stressing the subjective
side of pain and its linguistic articulation.
Unfortunately, however, the definition’s emphasis on the connection between pain and
full linguistic competence have led to a neo-Cartesian tendency to make such linguistic
competence a necessary and sufficient condition for attributing pain to a being (Descartes had
famously argued that only creatures with language could be said to possess mind.) “Mere”
behavior does not license the confident or certain attribution of pain to an organism because only
words describe the subjective. As Merskey says: “The behavior mentioned in the definition is
behavior that describes the subjective state and that is how matters should remain”. Merskey
also stated:
The very words “pain behavior” are often employed as a means to distinguish between
external responses and the subjective condition. I am in sympathy with Anand and Craig
in their wish to recognize that such types of behaviour are likely to indicate the presence
of a subjective experience, but the behavior cannot be incorporated sensibly in the
definition of a subjective event.
Despite Merskey’s own professed belief that “there is an almost overwhelming
probability that some speechless organisms suffer pain, including neonates, infants and adults
with dementia” (he does not mention animals), he nonetheless classifies such pain as “probable”
or “inferred,” in contradistinction to the certainty accompanying claims by linguistic beings. As
Anand and Craig and Craig have argued, this ultimately draws a major ontological and
epistemological gulf between linguistic and nonlinguistic beings in relation to the presence and
certainty of experienced pain. This, in turn, helps to justify the well-documented tendency of
researchers and clinicians to undertreat or fail to treat altogether pain in neonates, infants, young
children, and animals, all of whom lack full linguistic ability.
It is thus disturbing to find a neo-Cartesian element infiltrating these recent discussions of
pain, suggesting that only linguistic beings are capable of experiencing pain as something of
which they are aware, and that only verbal reports allow us to “really” know that a being is in
pain. Aside from the ethical damage that such a view can create by implying that animals,
neonates, and prelinguistic infants do not “really feel pain”, promulgation of this view is
dangerous to the methodological assumptions underlying science, as well as to scientific
credibility in society in general.
To illustrate the methodological pitfalls inherent in such a view, consider the thesis once
raised by Bertrand Russell: “How do we know that the world was not in fact created 10 seconds
ago, complete with fossils, etc. and us with all of our memories?” Or better yet, consider the
following critique of the very possibility of science: “Look here. Science claims to give us
explanations of phenomena that take place in the physical world we all share. Yet, in point of
fact, our only access to the real physical world is through our experiences, our perceptions,
which are totally subjective, unique to each perceiver. After all, it is notorious that I can’t know
what you perceive. You may not see red as I do, or hear sounds as I do. How then, do we ever
get to an "objective" world by summing a whole bunch of inherently subjective perceptions and
experiences?”
This, of course, is an argument for solipsism that few if any scientists worry about when
they attempt to explain the nature and causes of disease, earthquakes, atomic and subatomic
phenomena, mind, and so forth. Why don’t they worry about it? Because both of the
concerns detailed above are, like the existence of God or of an immaterial soul, ultimately
metaphysical hypotheses, which gathering data or doing experiments can never refute or
confirm, and scientific activity is archetypically tethered, however indirectly, to what can be
confirmed by observation and experiment.
Why go off on this tangent? Very simply, because the thesis that only linguistic beings
can feel pain or be aware of pain or give us evidence that they have pain is precisely such a
metaphysical thesis as well, to which no amount of data is ultimately relevant.
We all recognize that when we judge that another person feels pain, we are making a
fallible claim. The person (i.e., the linguistic being) may be malingering, faking, or acting. So
we seek other evidence: signs of injury; knowledge that the injury or condition in question
produces pain generally; we check our ability to lessen the pain with anesthetics or analgesics;
we look for involuntary moans and groans that the person may emit when fully or partially
asleep; and so on. Like all empirical claims, judgments that someone is in pain are in principle
falsifiable. The presence of language is certainly not definitive, as language can be used to
mislead and befuddle, as well as to inform. In practicing science or medicine, we go with the
weight of evidence: the presence of inflammation, guarding of a limb, change in pallor,
reluctance to eat, and so forth. No scientist of any credibility would affirm that he or she is
withholding judgment that another person feels pain in such circumstances just because the
scientist cannot, in principle, feel the same feeling the other person experiences, or perhaps does
not at all. In good scientific fashion, one goes with the weight of evidence, not with skepticism
based in untestable metaphysical possibilities. Doing the latter would be exactly like a scientist
rejecting another scientist’s experimental data solely on the grounds of the metaphysical claim
that he or she cannot be sure that the other person perceives at all, or perceives as we do because
we cannot experience their perception.
If science proceeds, then, by weight of empirical evidence in general and in the
attribution of felt pain in particular, and does not allow theses based in metaphysical possibilities
of solipsism (lack of absolute certainty that anyone else perceives as I do, etc.), then it is equally
a major logical error to deny felt pain to nonlinguistic beings a priori, regardless of what
physiological, behavioral, factual, or theoretical evidence exists to vouch for such felt pain!
Certainly, that evidence is abundant in our experience with animals, so much so that
ordinary experience, common sense, and language do not infer (or reason) that an animal is in
pain, but perceive it immediately. If a dog is run over by a car, is not unconscious, has a
compound fracture jutting out of his skin and a crushed limb, is howling and whining and
shivering, we automatically assume he is in pain. If someone asks, “But how do you know?”,
we assume that he is either demented or making a bad joke.
No one knows better than pain scientists that this powerful, unshakeable, common sense
response is strongly buttressed by myriad scientific evidence such as the following: that animal
pain physiology and neuro-anatomy is essentially the same as human well down the phylogenetic
level; that pain biochemistry – including the emergence of endogenous opiates after trauma and
the presence of such chemicals as bradykinin and substance P in painful areas – is similarly
phylogenetically continuous; that pain behavior and signs of pain, while certainly different in
some marked ways across species, is no more different than it is across human cultures and
subcultures, and is very similar in many ways (punch a Doberman pinscher, a tiger, a buffalo, a
shark, and a gangbanger in the mouth and see the reaction, if you still doubt me; recall the
guarding of limbs across species, etc.); that Darwinian evolutionary continuity makes the
emergence of felt pain in humans alone highly suspect, especially given the above-mentioned
similarities; that if animals did not feel pain, they could not serve as pain models for humans in
pain and analgesia studies; that anesthetics and analgesics seem to have the same beneficial
effects on animals as in humans, from quieting signs of suffering to accelerating healing; that
preemptive analgesia works the same in humans and (at least) in mammals.
Indeed, let us recall that one eminent pain physiologist, the late Dr. Ralph Kitchell,
co-editor of the American Physiological Society symposium volume on animal pain, has argued
for the possibility that animals in general, feel pain more acutely than humans. According to
Kitchell, response to pain is divided into a sensory-discriminative dimension and a
motivational-affective dimension. The former is concerned with locating and understanding
the source of pain, its intensity, and the danger with which it is correlated; the latter with
escaping from the painful stimulus. Kitchell speculates that since animals are more limited than
humans in the first dimension, since they lack human intellectual abilities, it is plausible to think
that the second dimension is correlatively stronger, as a compensatory mechanism. In short,
since animals cannot deal intellectually with danger and injury as we do, their motivation to flee
must be correlatively stronger than ours –in a word, they probably hurt more.
There is no question in my mind that what we call language is unique to humans, and,
very speculatively, something approximating language to a few other species, perhaps great apes
and dolphins. That does not mean, however, as Descartes and our current Cartesians conclude,
that language is the only sure way we can know that a being is in pain, fear, anxiety, distress, joy,
sexual excitement, and other fundamental and basic modes of awareness. I have argued
elsewhere against the traditional belief that there is a clear and unbridgeable gulf between the
sort of meaning we find in natural signs (e.g., clouds mean rain or smoke means fire) and the sort
of meaning we find in conventional (or man-made) signs, such as the word “cloud” in English
means,…“visible condensed water droplets.” As philosopher George Berkeley affirmed, nature
is full of meaning, and science can be viewed as, in his metaphor, learning to read the language
of nature. Animals, although presumably lacking language, find meaning in the world (e.g., a
scent meaning prey) and also impart meaning to other animals and humans (e.g., threats).
It is possible to suggest that a being with language can communicate better about the
nature of pain than one lacking language, but even if this is true, that does not mean that one
cannot communicate the presence and intensity of pain without language, by natural signs.
Recall that language does not help us much in describing our pain to others; verbal reports are
notoriously unreliable. Recall too that in addition to helping us communicate, language helps us
prevaricate and conceal. The posture and whimpering of an injured animal or the groans of an
injured person are, in my mind, far more reliable indicators of the presence and intensity of pain
than are mere verbal reports. Let us further recall that the natural signs we share with animals
are far more eloquent and persuasive signs of primordial states of consciousness like love, lust,
fear, and pain then is Shakespearean English – words fail in the most fundamental and critical
areas (as when a physician asks you to describe your pain).
It has sometimes been suggested that the possession of linguistic concepts is related to
pain in the following way: Only a being with language, and the temporal concepts provided by
language, can project ahead into the future or backwards into the past. Much of our pain is
associated with such projection – the pain of a visit to the dentist is surely intensified by the
magnified recollections of previous pain, filtered through imaginative anticipations of horrific
future scenarios informed by having seen the movie Marathon Man, wherein one’s dentist turns
out to be (literally) a Nazi war criminal. In the absence of concepts of past and future, animals
cannot recollect or anticipate, being, as it were, stuck in the now. Thus, the claim is that their
pain is considerably more trivial than ours.
Aside from the obvious objections – if animals have no access to the past, how can they
learn (which they clearly do); if animals have no concept of the future, how can a dog beg for
food or a cat wait patiently for a mouse (which they clearly do) – there is a much more profound
issue raised by this argument. If animals are indeed inexorably locked into what is happening in
the here and now, as the above argument suggests, we are all the more obliged to try to relieve
their suffering, because they themselves cannot look forward to or anticipate its cessation, or
even remember, however dimly, its absence. If they are in pain, their whole universe is pain;
there is no horizon; they are their pain. So, if this argument is indeed correct, then animal pain
is terrible to contemplate, for the dark universe of animals logically cannot tolerate any glimmer
of hope within its borders.
In less dramatic and more philosophical terms, Spinoza pointed out that understanding
the cause of an unpleasant sensation diminished its severity, and that, by the same token, not
understanding its cause can increase its severity. Common sense readily supports this
conjecture; indeed, this is something we have all experienced with lumps, bumps, headaches, and
most famously, suspected heart attacks which turn out to be gas pains.
Spinoza’s conjecture is thus borne out by common experience and by more formal
research. But this would be reason to believe that animals, especially laboratory animals, suffer
more severely than humans, since they have no grasp of the cause of their pain, and thus, even if
they can anticipate some things, have no ability to anticipate the cessation of pain experiences
outside their normal experience.
We further know that humans who cannot feel pain, even though they have the full
nociceptive machinery, do not fare well as far as survival is concerned. Whether the inability to
feel pain is a genetic anomaly or a result of diseases like Hansen’s disease or diabetes, such
human lose limbs, contract infection, and have truncated lives. Is it really plausible to suggest
that all animals without language are permanently in that state? And if they are, how do they
thrive?
One final argument against making the possession of language a necessary condition for
feeling pain: Philosopher Thomas Reid pointed out, quite reasonably, that since babies are not
born linguistic beings, they must acquire it. Even if Chomsky is correct that the skeleton for
language is innate, it must still be actualized by experience of some language. This in turn
entails that people must be capable of experience before they have language, else they could not
learn it (or actualize their innate capacity for it). But if nonlinguistic (or prelinguistic)
experience is possible, surely one of the most plausible candidates for such experience is pain,
first of all because it is so essential to survival, and secondly, because we have so much evidence
(discussed earlier) that nonlinguistic beings in fact experience pain!
For all of these reasons, then, including linguistic ability in the requirements for feeling
pain or attributing pain to another represents a combination of bad science and bad philosophy.
I went on to argue that this definition leads to bad ethics among scientists in ignoring
treatment of pain in non-linguistic beings, and also a bad picture of science to society, something
very undesirable at a historical moment wherein society has lost the old utopian confidence in
science and scientists. Presumably, some sense of the moral/political climate drove IASP to
modify this definition in 2001 in a minimalistic way. In a note, the definition now affirms that:
The inability to communicate verbally does not negate the possibility [emphasis mine]
that an individual is experiencing pain and is in need of appropriate pain-relieving
treatment.
This sounds far more like a concession to political reality than the embracing of a major
conceptual upheaval.
In any event, the attitude exhibited in the IASP definition is perfectly consonant with
what we have documented about human pain and, given the situation with human pain, the
reader can guess how cavalierly animal pain was treated.
Indeed, for younger people trained before the late 1980s, it is difficult to fathom the
degree to which the denial of consciousness, particularly animal consciousness and particularly
pain, was ubiquitous in science. In 1973, the first U.S. textbook of veterinary anesthesia was
published, Lumb and Jones. Although the book gave numerous reasons for anesthesia (to keep
the animal from hurting you; to keep it from injuring itself; to allow you to position the limbs for
surgery) the control of felt pain was never even mentioned. When I went before Congress in
1982 to defend our laboratory animal legislation, I was advised to demonstrate that such laws
were needed. To accomplish this goal, I did a literature search on laboratory animal analgesia
and, mirabile dictu, found only one or two references, one of which argued that there should be
such knowledge!
In 1983, the crescendo of concern among the public about animal pain was so great that
the scientific community felt compelled to reassure the public that animal pain was indeed an
object of study and concern, so they orchestrated a conference on pain and later published a
volume entitled Animal Pain: Perception and Alleviation. Despite the putative purpose of the
volume, virtually none of the book was devoted to perception or alleviation of felt pain. As a
result of scientific ideology, pain was confused with nociception, so that the volume focused on
the neurophysiology and electrochemistry of pain, what I at the time called the “plumbing of
pain”, rather than the morally relevant component of pain, namely that it hurts.
Most surprising to members of the general public is the fact that veterinarians were as
ignorant and skeptical about animal consciousness, even animal pain, as any scientist. To this
day, and certainly in the 1980s, veterinarians called anesthesia “chemical restraint” or “sedation”
and performed many procedures, e.g., horse castration, using physical restraint, what was
jocularly called “bruticaine,” or using paralytic drugs like succinylcholine chloride, which is a
curariform drug inducing flaccid paralysis, not anesthesia. Indeed, one veterinary surgeon told
me that, until he taught with me, it never dawned on him that the horse being castrated under
succinyl hurt!
This sort of absurdity also occurred in physiological psychology. I have already
mentioned the psychological community’s rejection of animal consciousness. Yet the same
community regularly performed stereotaxic brain surgery and brain stimulation using
succinylcholine without anesthesia, because the psychologists wanted the animals “conscious.”
That ideology could trump logic and even reason was manifest in this area. In the late
1970s, I debated a prominent pain physiologist. His talk expounded the thesis that since the
electro-chemical activity in the cerebral cortex of the dog (his research model for studying pain)
was different from such activity in the human, and since the cortex was the seat of processing
information, the dog did not (really) feel pain the way humans did. His talk took an hour, and I
was expected to rebut his argument. My rebuttal was the shortest public statement I ever made.
I said, “As a prominent pain physiologist, you do your work on dogs. You extrapolate the
results to people, correct?” “Yes,” he said. “Excellent”, I said. “Then either your speech is
false or your life’s work is!”
In a similar vein, I experienced the following incident. In the mid 1980s, I was having
dinner with a group of senior veterinary scientists, and the conversation turned to the subject of
this chapter; namely, scientific ideology’s disavowal of our ability to talk meaningfully about
animal consciousness, thought, and awareness. One man, a famous dairy scientist, became quite
heated. “It’s absurd to deny animal consciousness,” he exclaimed loudly. “My dog thinks,
makes decisions and plans, etc., etc.,” all of which he proceeded to exemplify with the kind of
anecdotes we all invoke in such common-sense discussions. When he finally stopped, I turned
to him and asked. “How about your dairy cows?” “Beg pardon?” he said. “Your dairy cows,”
I repeated; “do they have conscious awareness and thought?” “Of course not,” he snapped, then
proceeded to redden as he realized the clash between ideology and common sense, and what a
strange universe this would be if the only conscious beings were humans and dogs, perhaps
humans and his dog.
A colleague of mine, who was doing her PhD in the mid-1980s in anesthesiology, was
studying anesthesia in horses. The project involved subjecting the animal to painful stimuli and
seeing which drugs best controlled the pain response. When she wrote up her results, her
committee did not allow her to say that she “hurt” the animals, nor could she say that the drugs
controlled the pain – that was ideologically forbidden. She was compelled to say that she
subjected them to a stimulus and to describe how the drugs changed the response.
There were many rationalizations ingrained in researchers and veterinarians buttressing
the formidable ideological denial of pain in animals. For example, it was dogma among
surgeons that the post-surgical whimpering, shivering, crying that I saw as indicative of pain in
post-surgical animals was not pain at all, but after-effects of anesthesia as mentioned earlier.
When pressing for analgesia, I was told that the pain was necessary to keep animals still after
surgery or injury. In actual fact of course, animals are smart enough to avoid exertion when sick
or injured. It is humans who keep working or playing. Furthermore, as we know from our own
experiences of analgesia it does not eliminate pain, rather it raises our pain-tolerance threshold,
so that we do not suffer as much.
Still others affirmed that cattle did not need post-surgical pain control because they “eat
right after surgery” and thus could not possibly be in pain. Because of such stoic behavior,
some veterinarians still do spays (and of course castrations) on cattle with no anesthesia. The
answer, of course, is that stoic behavior does not prove that the animals are not feeling pain. We
need to recall that cattle are a prey species, and in nature, herds of cattle are always accompanied
by circling predators, ever-vigilant to signs of weakness or debilitation. Any cow that did not
therefore behave normally when painful would be quickly culled by predation.
It was claimed that dogs did not hurt after abdominal surgery for anatomical
reasons—their viscera are suspended in a mesenteric sling. Similarly, one heard that dogs were
alert and wagging their tails post-surgically so they surely did not hurt. Various researchers
have done much to dispel such myths. Veterinarian Dr. Bernie Hansen has regularly pointed out
that the presence of humans in a post-surgical ward significantly skews the animals’ behavior,
and that one sees a different story when one videotapes the animals in the absence of humans.
In one particularly dramatic tape, Hansen shows a Malamute dog who had experienced major
disk surgery, yet in the presence of people, sat up putatively bright and alert, and never even lay
down to rest. The taping provided dramatic new evidence. When people were not present, the
dog would involuntarily start to sink into a sleeping position. But his back hurt so much that
any attempt to lie down would awaken him, as evidenced by a pathetic series of cries and
whimpers!
As mentioned earlier, the Federal legislation did much to eliminate agnosticism about,
and denial of, felt pain in research animals and to force its use even by those who remain
agnostic, federal law being one of the few levers powerful enough to overturn ideology. Papers
on analgesia and pain have proliferated, and in general the analgesia requirements are quite well
enforced by Animal Care and Use Committees. Since most veterinarians in academe do
research, they have communicated the need for and methods of pain control to their students,
who in turn take this knowledge, plus the social-ethical imperative to control pain, into their jobs
after they graduate.
Equally important, with the extraordinary augmentation of the emotional role that
companion animals play in people’s lives, public demand for pain control for their animals has
become loud and forceful. This not only has forced veterinarians in practice to set aside their
denial of pain, it has again led to increased academic attention to pain control. Once again,
social ethics drives transcendence of ideology.
In addition, there is suddenly a huge market for pain control in animals, and the drug
companies were not slow to acknowledge this. Particularly relevant to our discussion is the
story of Pfizer and Rimadyl®. Rimadyl® is the trade name for carprofen, a non-steroidal
anti-inflammatory drug used for analgesia in skeleto-muscular problems. Originally developed
as a human drug, carprofen showed no great advantages over other anit-inflammatories, and thus
was not marketed. However, someone at Pfizer thought of trying it on dogs, where it gave
spectacular pain control results. Pfizer began a successful advertising campaign showing older
dogs unable to romp because of skeleto-muscular pain and affirming that Rimadyl® could control
such pain. Shortly thereafter, I was approached by Pfizer representatives who told me that the
biggest obstacle to marketing the drug was veterinarians, whose ideology-based denial of animal
felt pain prevented them from prescribing pain control! In what was surely a first for a
philosopher, I worked with Pfizer to help lay bare these ideological presuppositions and
overcome them. In the end, Rimadyl®, it is rumored, sold close to $1 billion in one year soon
after being marketed.
One can argue that, in terms of rate of change, the control of animal pain probably
proliferated far more rapidly than what we have indicated about human pain. I largely credit the
Federal law and the animal research community, who “recollected” common sense and common
decency about animal pain when faced with the law. With no law driving control of pain in
babies, children, or the disenfranchised, change has been slower. On the other hand, aggressive
social concern about pain has created increasing amounts of attention to it. Both human and
veterinary medicine now specifically address pain management in the process of accrediting
hospitals.
One need only look at the over-the-counter medication for sale in any pharmacy to realize
that, at the present, we are not a culture that makes a virtue of stoic enduring of pain and
suffering. This is not only true of physical pain—commercials relentlessly press mood-altering
drugs, male erectile enhancers, and cures for the “heartbreak of toe-nail fungus” (I am not
making this up!). The Spartan ideal of stolid acquiescence while a fox disembowels you is a
source of amazement in all but farm kids, athletes, and some military professionals. Pectoral
implants and calf implants, simulating musculature in men without the hard work, are among the
fastest growing procedures in plastic surgery.
Though I cannot prove this claim, it seems fairly evident that the neglect of felt pain in
human and veterinary medicine has drawn people to alternative medicine. Alternative
practitioners, if nothing else, are generally highly sympathetic and empathetic. Whether their
treatment modalities work or not, they project care and concern, which people sometimes forget
is not a substitute for effective treatment. Purveyors of effective treatment, possessed by
scientific ideology, may be guilty of lack of empathy, and may focus only on the disease. The
result is an extraordinary groundswell of support for alternative medicine, including modalities
that have been shown not to work or cannot possibly work (e.g., homeopathy) if modern science
is true!
This may appear unintelligible to scientists—after all, how can people opt for what
doesn’t work over what works. The key point, though, is to remember what people mean by
“what works.” When ordinary people say assuredly that someone is a “good doctor” or a “good
vet” they do not mean that they have studied the practitioners’ cure rate or educational
credentials—they mean that they are empathetic and seem to care. Thus it is obviously not
enough for scientific medicine to do well on double-blind clinical trials. It must also meet
socio-ethical demand for empathy, and control of pain and suffering. And this, of course, means
that it must abandon scientific ideology’s ignoring or bracketing subjective states as irrelevant!
It does not mean, in my opinion, trying uneasily to coexist with non-evidence-based alternative
medicine!
One final issue needs to be discussed. It will be recalled that the federal laboratory
animal laws that forced what we have called the “reappropriation of common sense” on pain also
contained a proviso mandating control of “distress.” Beginning in 1985, however, the USDA,
in writing regulations interpreting the Act, focused exclusively on pain, thereby upsetting many
activists. In my view, this was extremely wise, though not necessarily intentionally so. The
point is that now USDA has begun to look at distress, but is doing so after the acceptance of pain
has become axiomatic. Had they demanded control of pain and distress from the beginning,
little progress would have been made on either category, the dual task appearing far too
formidable to allow for progress on either front!
The situation is quite different now. I recently attended a conference of experts on how
to deal with “distress.” The preliminary discussion illuminated a fascinating leitmotif common
to many participants. “While pain is tangible, real easy to get hold of,” the argument went,
“distress is far more amorphous and opaque.” I was genuinely amused by this, and altered my
keynote address to acknowledge the source of my amusement. “Almost 25 years ago exactly,” I
said, “I attended a very similar conference on pain, sponsored by the same people. At that time,
I argued that animals felt pain, and that that pain could be known to us and controlled. An NIH
official was there and said nothing, but called the Dean of my school to tell him that I was a
viper in the bosom of biomedicine, and students should not be exposed to my ideas! The point
is that felt pain was as remote and outlandish to scientific ideology then as distress seems to be
today.” I also pointed out that if 500 million dollars were made available for distress research, it
would not go begging and unclaimed! The distress issue, too, is simply reappropriating
ordinary common sense on negative mental states or emotions in animals, such as fear, boredom,
loneliness, social isolation, anxiety, etc, and then providing science-based clarification of these
concepts and their operational meaning and criteria for identifying them. I am morally certain
that in 25 years, in retrospect, distress will look as transparent as pain!
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See for example, B. Rollin, The Unheeded Cry
Ibid.
D. Callahan, “Death and the Research Imperative”
R.M. Markes and E.S. Sacher, “Undertreatment of Medical Impatients with Narcotic Analgesics”
J. Liebeskind and R. Melzack, “Meeting a Need for Education in Pain Management”
B.R. Ferrell and M. Rhiner, “High-tech Comfort: Ethical Issues in Cancer Pain Management for the 1990s”
E. Gray, “Do Respiratory Patients Receive Adequate Analgesia?”
M. Pernick, A Calculus of Suffering: Pain, Professionalism and Anesthesia in Nineteenth Century America
G.A. Walco et.al., “Pain, Hurt, and Harm: The Ethics of Pain Control in Infants and Children”
D.K. Cope, “Neonatal Pain: The Evolution of an Idea”
CIRP, “Pain of Circumcisision and Pain Control”
K.J.S. Anand and P.R. Hickey, “Pain and its Effects in the Human Neonate and Fetus”
K.J.S. Anand and P.R. Hickey, “Halothane-Morphine Compared with High Dose Sufentanil for Anesthesia and
Post-Operative Analgesia in Neonatal Cardiac Surgery”
Ibid.
Walco et.al., op. cit.
B.H. Lee, “Managing Pain in Human Neonates: Implications for Animals”
S. Beggs, “Postnatal Development of Pain Pathwayss and Consequence of Early Injury”
Walco et.al., op. cit.
Ibid.
L. Robins et.al., “Drug Use in U.S. Army Enlisted Men in Vietman: A Follow-up on their Return Home”
Metro Health Anesthesia, “History of Ketamine”
B.Rollin, “Pain, Paradox, and Value”
R.E. Johnstone, “A Ketamine Trip”
Ibid., p.461
Ibid., p.461
See cases in Erowid Experience Vaults on the web, e.g. Abe Cubbage, “A Trend of Bad Trips”
B.E. Rollin, “Some Conceptual and Ethical Concerns About Current Views of Pain”
International Association for the Study of Pain, Pain Terms: A List with Definitions and Notes on Usage
Recommended by the IASP Subcommittee on Taxonomy”
H. Merskey and N. Bogduk, Classification of Chronic Pain: Description of Chronic Pain Syndrome and Definition
of Pain Terms
Ibid.
H. Merskey, “Consciousness and Behavior”
H. Merskey, “Response to Editorial: New Perspectives on the Definition of Pain”
H. Merskey, “Consiousness and Behavior”
KJS Award and K.D. Craig, “New Perspectives on the Definition of Pain”
K.D. Craig, “Implications of Concepts of Consciousness for Understanding Pain Behavior and the Definition of
Pain”
B. Russell, The Problems of Philosophy
R. Kitchell and M.J. Guinan, “The Nature of Pain in Animals”
B. Spinoza, Ethics (Parts 3-5)
T. Reid, Inquiry Into the Human Mind on the Prnciples of Common Sense, Chapter 5
IASP website, IASP Pain and Teminology: Pain
W. Lumb and E.W. Jones, Veterinary Anesthesia
D.W. Ramey and B.E. Rollin, Complementary and Alternative Veterinary Medicine Considered
Kitchell, R.L., and Erickson, H.H. (eds.), Animal Pain: Perception and Alleviation,
and Johnson, R.D., ‘Assessment of pain in animals’, in G. Moberg (ed.), Animal Stress